MEDICARE: ALLEGIANCE DENTAL INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	32622	CA

General Provider Information

NPI Number	:	1740569631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLEGIANCE DENTAL INC

Provider Business Mailing Address
First Line	:	4690 GENESEE AVE
Second Line	:	SUITE B
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-3000
Country	:	US
Telephone Number	:	858-279-6100
Fax Number	:	858-279-6112

Provider Business Practice Location Address
First Line	:	4690 GENESEE AVE
Second Line	:	SUITE B
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-3000
Country	:	US
Telephone Number	:	858-279-6100
Fax Number	:	858-279-6112

Authorized Official
Title or Position	:	OWNER
Name	:	STUART T TANI
Credential	:	DDS
Telephone Number	:	858-279-6100

Provider Enumeration Date	:	08/09/2011
Last Update Date	:	06/29/2012

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Directions to “ALLEGIANCE DENTAL INC ” Practice Location

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